Provider Demographics
NPI:1255407631
Name:MOGAKA, JORAM O (MD)
Entity type:Individual
Prefix:DR
First Name:JORAM
Middle Name:O
Last Name:MOGAKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4967 CROOKS RD
Mailing Address - Street 2:STE 130
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5801
Mailing Address - Country:US
Mailing Address - Phone:248-952-1601
Mailing Address - Fax:248-952-1614
Practice Address - Street 1:22631 GREATER MACK AVE
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-2055
Practice Address - Country:US
Practice Address - Phone:586-771-0100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI076566207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI810666394OtherTAX ID
MI1108235572OtherBLUE CROSS BLUE SHIELD
MI472234510Medicaid
MI1106314802OtherBLUE CARE NETWORK
MIH84913Medicare UPIN
MI0P15370Medicare PIN